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The Interview

Chanda Rankin: I'm Chanda Rankin, and it's a real pleasure to have you here for this interview today with Psychotherapy.net. Earlier you mentioned you were born in Vienna, Austria. I wanted to know how much sociocultural influences at that time affected and influenced you to go into the field of psychotherapy and analysis.

Otto Kernberg: To begin with, I left Austria when I was ten years old. My parents and I had to escape from the Nazi regime. We did so at the last moment and immigrated to Chile. I trained in psychiatry at the Chilean Psychoanalytic Society. I came to the States for the first time in 1959 on a Rockefeller Foundation fellowship to study research in psychotherapy with Jerry Frank at Johns Hopkins. Then in 1973 I moved to New York, where I was at Columbia. Now, I'm Director of the Personality Disorders Institute where we're carrying out the research of personality disorders.

Certainly my cultural influences are Austrian, German, and that has influenced me in many ways. But my psychiatric training was integration of classical descriptive German psychiatry and psychoanalytic psychiatry/psychodynamic psychiatry. Later I became immersed in ego-psychology and Klein's work. I also visited Chestnut Lodge where I became acquainted with the culturist orientation, Sullivanian, Frieda Fromm-Reichman as well as the ego/object relations psychologists, Edith Jacobsen and Margaret Mahler. So it was natural to try to synthesize an object relations approach between the great ego psychological Kleinian and so-called British 'middle group' or independent approaches. Then many years later, to this was added a certain influence from French psychoanalysis.

Kernberg's Gold Mine

CR: I've always been very curious about what is it about working with personality disorders do you find so compelling that you've made this the focus of your life's work?

OK: It was a combination of various influences. First of all, perhaps the most important one was that the psychotherapy research project at the Menninger Foundation that I joined and eventually directed consisted of the treatment of 42 patients—21 treated with various types of psychotherapy from a psychoanalytic basis, and 21 patients were treated with standard psychoanalysis. Now, it so happened that many of the patients sent to the Menninger Foundation suffered from severe borderline conditions. Severe personality disorders, right now called Borderline Personality Organization...the concept had originally been developed there by Robert Knight and his coworkers. Many patients with severe personality disorders were included in that project, and the diagnosis was made very, how shall I put it, tentatively or fleetingly. When the project started in 1954, there were no clear-cut criteria being used. It was very helpful because it turned out that half of the patient population on the therapy side, and half of the patient population on the psychoanalysis side suffered from severe borderline conditions.

CR: How fortunate for the researchers.

OK: Yes. And each of these cases had typed process notes of each session, of treatment over many years. Big fat books. So by the time I got there, I had 42 cases studied in detail, and it was just a gold mine! I noticed regularities about what happens in the treatment, what would have facilitated the diagnosis, so I combined my interest in object relations theory with the interest in clarifying this group, to develop some hypothesis about treatment. We then did the statistical and quantitative analysis of the project. It provided me with important confirmations and disconfirmations of the hypothesis.

CR: And this population was not well understood at the time.

OK: No, so I was very lucky to have this patient population. And when I started out, I wasn't aware myself that I was getting into a very interesting subject.

CR: How did you become involved with the study of narcissistic personality disorders?

OK: Just by chance. One of the patients who I saw in a controlled analysis while I was a student at the Psychoanalytic Institute in Santiago, Chile, had been diagnosed as an obsessive-compulsive personality. I was unable to help him—he didn't change one inch over years and his memory persecuted me. Then, I perceived that he was very much like other patients I saw at the Menninger Foundation. Hermann Van Der Waals, who had written an important article on the narcissistic personality told me, 'These are narcissistic personalities.' Nobody had described these characteristics in the literature well.

I then took another patient into analysis, exactly like my previous one, and on the basis of my then-developing psychoanalytic knowledge, I developed a particular thesis on how to treat that patient. And this is how I developed the treatment of narcissistic personality, the diagnostic observations, the differential diagnosis between narcissistic and borderline typology, the generalization of the concept of borderline personality organization. So it was a combination of luck and interest.

CR: A very rich time, and a confluence of things coming together to make that happen. What or who influenced your clinical style which seems to be neutral in many ways but not passive or impersonal?

OK: One individual who I have not yet mentioned, who is very little known at this point, although he was a leader of American psychiatry, is John White, the Chair of Public Psychiatry of Johns Hopkins when I was there. He developed a method for clinical interviewing that inspired me for developing structural interviewing. He was the best interviewer I've ever seen. He would start talking with the patient, and the interview would go on until he had a sense that he knew what he wanted to do. It went on for two or three hours. John White had a way of putting himself into the background, disappearing, so to speak. He was very direct, very honest, and understood something about people, in depth. No showmanship. Just raising questions that permitted the development of the patient. He had a tremendous capacity to permit the patient to develop his present personality, rather than asking what happened 50,000 years ago. That also influenced me in interviewing. Sharpened my approach to the study of the present personality.

But, perhaps also what has been very important to me is the excitement with the fact that there you have these patients with severe distortions, that ruin their lives. No doubt about it. This is not phony pathology for wealthy patients who have nothing to do but to go to a psychoanalyst. These people have not been able to maintain work, a profession, a love relation. And with the psychoanalytic psychotherapy and psychoanalysis you are able to change their personality, improve their lives. I think that is an extremely important contribution of psychoanalysis. And we need to do empirical research on this. One of the things that I have been very critical about is the lack of systematic and empirical research within the psychoanalytic world.

How People Change!

CR: Do you think that there's any one specific thing, if at all, that contributes more than any other thing to change with a personality-disordered patient?

OK: People change in many ways with common sense, with friends, with help, with luck, with good experiences in life. I think that psychoanalytic psychotherapy and psychoanalysis are probably the methods that promote the best changes in case of severe personality disorders, through the mechanism of analyzing of the transference, the split off, dissociated, primitive object relations that determine and are an expression of identity-fusion, bringing about normalization of the patient's identity, integrating his self and concept of significant others. In that context, permitting the advance from primitive to advanced defense mechanisms, and strengthening of ego function in terms of increased impulse control, moderating affective responses, and facilitating sublimatory engagements.

So I think that's probably the best approach nowadays to bring about fundamental personality change. There are indications and contra-indications; not all patients can be helped. I think that the prognosis depends on the type of personality disorder, on intelligence, on secondary gain, on the severity of anti-social features, on the quality of object relations, on the extent to which some degree of freedom of the sexual life has developed or not. So there are many features that make indication, contra-indication and prognosis for the individual cases different. We are in the middle of trying to spin all of these out.

"Psychotherapy Training is Going Down the Drain"

CR: You often emphasize the importance of training, really making sure that the therapists know what they are doing and what they are dealing with in terms of the patient. Can you speak to that issue?

OK: First of all, yes, I am very critical of chaotic gimmickry in treating patients based upon chaotic theory. Each person who invents a treatment method invents his own ad hoc theory for treatment. I find that this damages the field, the treatment, the patients. It's bad science, on top of it. One thing I like about psychoanalysis is that it's an integrated theory of development, structure, psychopathology, that lends itself to develop a theory of technique of intervention. I'm not saying it's the only one, but that's one of its strengths.

I think that when people apply various techniques from different theoretical models, they cannot but end up in a chaotic situation in which transference and countertransference is going to drive the relationship in one direction or another. I'm not saying that you can't help patients with this. But you cannot learn how to develop a certain approach. I've seen so many bad consequences from that. Because then you don't match technique with the needs of the patient. And you don't give patients as much. So I prefer to have a cognitive-behavioral therapist, let's say, a well-integrated general theory that applies to his field, rather than one of these esoteric schools everybody has. In this field there is so much voodoo and so much fashion and quackery. It's paid for, and of course, it requires research. Now, unfortunately, most of the research that's been done on short-term psychotherapy done by non-therapists with non-patients in university settings, to grind out papers... so the real treatment that is done clinically has only been researched in a limited way... I think that's our major task. And I believe that we need to develop manualized treatments for long-term psychotherapists, whatever their background. And test them scientifically.

So, regarding training, I think that training should focus on theory of personality, personality change as a basis of technique. And then, apply it to clinical situations.

CR: What do you think of the impact of managed care on psychotherapy?

OK: Psychotherapy training is going down the drain in this country, under the corrupting effect of managed care, this terrible system for profit that goes under the mask of 'managed care,' but really it's managed cost. Under its pressure, long-term psychotherapy is now reserved for those who can pay for it privately. So we are depriving a significant segment of the population of treatment. I trust that that system is going to explode by its own corruptive effects and structure. This is already occurring. And that in the long run, our knowledge and our scientific development of psychotherapy will restore an optimal level of psychiatric practice and psychotherapeutic practice. I think that in the meantime we live in a happy-go-lucky, democratic fashion in which everything goes. Which creates distrust in the public, cynicism in the profession, and is not healthy to patients.

CR: Have you considered ways to reverse this trend?

OK: I think the solution is, in the long run, scientific research.

In my own Institute of Personality Disorder, we're trying to contribute in a modest way by carrying out empirical research. We have randomized three groups of 40 patients each, all of them with the diagnosis of Borderline Personality Disorder. One group to be treated with transference-focused psychotherapy, which is a psychoanalytic psychotherapy that we have developed and tested. The second group by DBT, Dialectical Behavioral Therapy, developed by Marsha Linehan for suicidal Borderline patients. And third, supportive psychotherapy based on psychoanalytic principles. We're going to compare these treatments, not simply in a kind of horserace, but we're trying to study what process mechanisms are connected with what mechanisms of change.

I don't believe that one treatment is 'better' than the others, but there are specific types of patients who respond better to one or another or that treatments may be equally good on the basis of different mechanisms of change. In this regard, I'm very critical of the assumption that non-specific aspects of psychotherapy are by far the overriding cause of its effectiveness. Because all the studies on which these conclusions are based are short-term psychotherapists of very questionable nature. Nobody has studied yet the comparison of long-term psychotherapists from the solid bases, as I have tried to define.

Critiquing the Media and Pop Culture

CR: To go back to something we were talking about earlier, I was wondering if you could say something about psychotherapists portrayal in the media? What are your thoughts on how psychotherapists are portrayed in movies and television?
Along those same lines, you have noted how eclecticism in the field is leading to a diffusion and misrepresentation.

OK: In general, psychotherapists are portrayed in simplified and almost caricatured ways in movies. What is very fashionable in this country right now is the so-called intersubjectivist approach, in which the therapist lets 'everything hang out' and people are impressed with how real the therapists are. I think that reflects a dominant culture of doing things quickly, immediately, the culture of faith, good faith, warmth, belief in the human being helps everybody along. Which is different from the reality when we treat patients who suffer under severe regressive conflicts, whose major need is to destroy the therapeutic relationship, who envy the therapist's capacity to help them—those kinds of cases we don't see in the movies, except that by the time we see that kind of patient, they are shown as monsters and people get horrified. And there is a strong cultural critique of psychoanalysis that is not new, but now takes the form of "psychoanalysis is lengthy, expensive, hasn't demonstrated its efficacy and effectiveness, and patients can be helped by brief psychotherapists." Often they present psychotherapy as shamanism.

At the same time, the combination of the important development in biological psychiatry, the financial pressures reducing availability of psychotherapeutic treatment, the cultural critique of subjectivity and wish for quick solutions, adaptation—all that has tended to decrease the participation of psychodynamic psychiatry and psychodynamic psychotherapy and the training of psychiatrists. It has brought about the old-fashioned split between biological psychiatry (centering on basic research and psychopharmacological treatment) and psychotherapy (pushed off to other professions and being disconnected from medicine and psychiatry). I think that's unfortunate. That leads to a kind of mind/body divide when they should come together.

CR: Can you say more about this mind/body divide?

OK: The impact of the new neurosciences on psychotherapy is very misunderstood. I think there is a lot of premature, reductionist excitement with all these new findings. We have important new findings of the central nervous system, as an effect of psychotherapy, correlations between psychiatric disorders and brain functioning. But these new developments do not, as yet, have any practical implications in terms of both theory and technique, technical interventions, so we have to keep that in mind.

CR: How do you view issues of the mind/body applying in the clinical situation?

OK: Of course you could say that it applies insofar as psychopharmacological drugs derived from our better understanding of neurotransmitters. That is certainly true for the case of schizophrenia, major affective disorders, syndromes of depression and anxiety in general, but it's not true for personality disorders, the many sexual difficulties and inhibitions that go with them. And, to the contrary, there, medication has a very limited symptomatic effect on anxiety and depression, but not at all on the basic psychopathology. The illusion that eventually everything is going to be cured by a pill is an illusion that has existed for a long time, and I think that there are good theoretical as well as practical, clinical, reasons to question it.

The Question of Love

CR: I want to turn to a different interest of yours which you explore in your new book Love Relations: Normality and Pathology. I was very curious how that came about, and in the body of all your other work to be writing a book on love seemed like such a drastic change. What was the impetus for this book?

OK: As I mentioned in the Introduction to the book, I have been accused of being only concerned with hatred and aggression, so I thought it would be fun to write about love!

CR: Was it fun to research and write this book?

OK: It was fun, but it was also difficult, because when I got into the subject, I realized how complicated it is, and how I had to renounce exploring many areas that I would have loved to explore. So the book has important limitations. I observation that the degree of pathology of the personality disorder, of one or both participants of the couple, does not permit us to establish a prognosis of how the couple would do. Two perfectly healthy people get together and it's like hell on earth; two extremely troubled people get together and have a wonderful relationship! So that clinical observation created my curiosity, because of course it's a problem that borderline patients face—establishing couples, getting married.

I also became interested in the subject of sexual relations, because I found out there were two types of borderline patients—I'm using the term loosely to mean severe personality disorders. One with an extremely severe primary inhibition of all sexual capacity, no capacity for sensual activation or enjoyment, no sexual desire, no capacity for masturbation. These patients had a bad prognosis because in the treatment, as everything was consolidating, more repressive mechanisms inhibits that sexuality even further. On the other hand, you had those with wild promiscuous sexuality—polymorphous perverse, invert, pan-sexuality, with masochistic, sadistic, voyeuristic, exhibitionistic, fetishistic, homosexual, heterosexual, everything...those with such a chaotic sexual life seem to have a terrible prognosis, but the opposite was true. These patients did extremely well, once their personality was functioning better. So it raised my interest, why this extremely severe sexual inhibition, what could be done about this? And, also, a more basic question about how much a couple can contribute to inhibit each other or to help each other to free themselves sexually. That's it, in a nutshell.

What are Good Therapists and Analysts Made Of?

CR: Do you have any thoughts about personality characteristics that an analyst or a therapist needs to have in order to work with severe personality disorders, or even mild personality disorders?

OK: That's a good question. As I look at our experience, we've trained many therapists. We've had 20 years of training and supervision. I think that people with very different personalities can become very good therapists. I don't have anything deep or new to say about this that couldn't be said by anybody with some experience in this field. I think it's important, first of all, that the therapist be intelligent, it helps. Second, that they are emotionally open. That they be a personality that is sufficiently mature, on the one hand, and open to primitive experience, in contrast to someone who is extremely restricted. It helps not to be excessively paranoid, infantile, or obsessive-compulsive. Although, I'm saying excessive because we have all kinds of therapists—all basically, honest with themselves and others, with a willingness to learn. Therefore, it helps not to have too much pathological narcissism. If you are too narcissistic, you don't have the patience to work with very troubled patients, and your capacity for empathy is limited.

CR: But it also seems like you need a healthy dose of those things.

OK: Yeah, some of us are exploring that. I really don't have a good answer to that. But there are some people who have a talent for it, like people have talent for playing piano. I don't know whether experts would say, what personality does it take to play the piano? There are some people who have the talent. Some people are able to do it almost without any training. It's almost frightening that they know things before we teach them. It's bad for our self-esteem! I've had therapists with whom I've had a sense that there is such an inborn capacity that with little...they would flourish. And others who never learned, even though they were intelligent and hard-working. And I'm not able, at this point, to spin out what it is. But, we can discover it.

Very simply, we tell people who want to train, "Bring us a tape. The best tape you have, of any session that you are carrying out, a videotape with a patient in treatment." And we have developed methods of the psychotherapeutic interaction by which we can sort out who does have the talent for doing it. We can evaluate very quickly with manualized treatment whether the therapist is able to adhere and whether the therapist is competent. Competence is seen by the therapist talking, focusing on what is relevant, focusing on what is relevant with clarity, doing it relatively quickly and in depth. Relevance, clarity, speed, depth. The combination of them tell us who is a good therapist. It's terribly simple, and it works.

And I'll tell you, some experienced psychoanalysts are terrible; and some young trainees are very good. This creates the problem: does one have to be a psychoanalyst to do this kind of treatment? I would say it helps to have psychoanalytic training, but it's not indispensable. There are some people who have so much talent they can do it without psychoanalytic training, although, a personal psychotherapeutic experience always helps, particularly if people have a kind of "blind spot" in a certain area. Sometimes a psychoanalytic treatment or psychoanalytic psychotherapy helps.

CR: You have written about the importance of therapist safety. It really hit home with me, and I had not actually heard anyone articulate that clearly before. The ability to be able to sense when safety is an issue seems so primary. So all the things that you're talking about—your own self-awareness, to be able to have the insight into these areas, to know when something is a problem. It's very important for safety as a therapist and also the amount of safety you can provide for your patient.

OK: Exactly right. It permits you to maintain the frame of the treatment. It's absolutely essential. The therapist has to maintain the control over the therapeutic situation. The therapist has to be in charge. There is a realistic authority of the therapist that has to be differentiated from authoritarianism, namely, the abuse of that authority. There is kind of a cultural move toward "democratization" of the psychotherapeutic relationship. I think that's just silly. Because patients come to us because of a certain expertise, otherwise they wouldn't come to us, and they shouldn't. There's a difference between authority and authoritarianism. And part of the authority of the therapist depends on the therapist's being able to maintain the frame of the treatment. And our own safety is essential in this regard. When you treat severe personality disorders it becomes crucial...physical, psychological, legal safety, in this country which is so litigious. It's the most paranoid culture that I know within the civilized world. I've not been in the jungle...

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Increase understanding of the treatment of severe personality disorders with psychoanalytic psychotherapy.

Identify key arguments for increased scientific research in the field of psychoanalysis and psychoanalytic psychotherapy.

Consider the impact of current trends in mental health care, such as managed care, eclectic training, and the use of medication, on the efficacy of treatment of personality disorders.

Bios

CE Test

Otto Kernberg, MD is the Director of the Personality Disorder Institute at the New York Presbyterian Hospital, Westchester Division, and Professor of Psychiatry at the Joan and Sandford I. Weill Medical College and Graduate School of Medical Sciences of Cornell University. He is also Training and Supervising Analyst of the Columbia University Center for Psychoanalytic Training and Research and is the Past-President of the International Psychoanalytic Association. He has received numerous awards for his excellence in Psychiatry and has authored or coauthored over twenty books.

Chanda Rankin currently holds a PhD in Clinical Psychology from the Wright Institute and a CADC II. She has a full-time private practice in Los Angeles as an addictions counselor. Dr. Rankin specializes in working with performing artists and other creative individuals. Dr. Rankin can be reached at 310-477-0443.

CE credits: 1

Learning Objectives:

Increase understanding of the treatment of severe personality disorders with psychoanalytic psychotherapy.

Identify key arguments for increased scientific research in the field of psychoanalysis and psychoanalytic psychotherapy.

Consider the impact of current trends in mental health care, such as managed care, eclectic training, and the use of medication, on the efficacy of treatment of personality disorders.

Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here